I worked the last three nights. My first night I picked up a SAH in her mid 30's, no hx but migraines. She went down for a coiling and came back that night fine. Her pressures were a little low, but she was intact. That morning the neurosurgeon came in and said he was going to address her pain (HA refractory to meds) and her pressure, so I left feeling good. The next night when I had her, she was still intact, but her pressures were still low, like in the 90s-100s. I called the intensivist twice about her pressures. The first time he said to bolus her, which did no good, and the second time he said that since she was intact to just watch her. I was having serious concerns at that time because even though she was intact, she had had a BIG bleed, including IVH and I knew she was going to spasm. I should add that despite the size of her bleed, she presented with a Hunt and Hess of II/IV. PLUS I knew her pressures were also low because she was getting a BOATLOAD of pain meds for severe unrelenting HA AND the nimodipine was dropping her pressure as well, even when I gave it 1 q 2h. Why were we not doing HHH on her?
SO, when I arrived last night, low and behold, the TCDs had shown SEVERE spasming and she now had a swan, an a line, and was on neo. THANK god. I also quite honestly felt I had not done enough in being an advocate for the pt and had decided that when I went back last night I was going to raise heck if the situation was still the same. Luckily, it wasn't. AND they did an LP. Her CSF was bloody, her WC, RC, and protein were through the roof and her glucose was 29. Sounds like....meningitis??? Hmmm. However, her serum WBC were 13, and she was afebrile.
Last night around 2100 she became a little lethargic/confused and started having a mild drift. I was already titrating up the neo, but I cranked it up more (we were shooting for a MAP of 110 and she was having a hard time getting there.) The intensivist was present and I discussed the situation w/ him. We were both in agreement that her pressures needed to go up and that she was getting lots of pain meds. So I watched her all night and continued cranking up her neo. By this morning she was at 150 mcgs. AND she was intact again, no drift, alert. Her MAP was 110-120. I had continued to give her pain medicine all night so I deduced that the pain meds were NOT making her confused as that had not changed. I felt I had done a good job that night of taking care of her, was pretty satisfied although exhausted. I was concerned that her WC was up to 17, NO atb tx, and she had started to c/o nuccal rigidity.
The neurosurgeon came in this morning with his intern/resident whatever and started throwing it around that she WASN'T spasming and basically laughing at the intensivist for everything he had done, which in turn I felt he was being condescending to me as well. He wanted to know who told me she was spasming. I replied that her nurse the day before had as well as the TCD report. As I was trying to explain what had happened the night before, he was too busy talking over me about how she's okay and doesn't need HHH and we need to titrate the neo off. The words ran right out of my mouth before I could even think. "you better not!" Of course, he didn't like that, but mostly just laughed about it with his groupies. Then he wanted to know who was taking care of her that day. I told him and he said "okay that's great." I also tried to tell him about her nuccal rigidity and he said it was from blood in the subarachnoid space. Which is fine, but w/ everything else....
When I was giving report, the nurse rec'ing said the surgeon had stopped her in the hall and said "she's not spasming, don't let anybody tell you otherwise." Who could he have been talking about???
And apparently he had at some point said she didn't have a SAH, she had bleeding in the basal ganglia. Ok, but she was coiled AND he told me she had blood in her subarachoid space.
So, the orders today from him were to titrate neo OFF w/ no parameters. And he was such a condescending jerk. My biggest concern though is that I feel this pt, who is very young, is going to be grossly mismanaged if indeed her pressors are weaned off.
I know this is so long, so I'll try to wrap it up. I know I have only been in NSICU for two years, so I am asking all of you what you think. Are TCDs NOT indicative of spasming and if not, WHY are we doing them? Am I totally wrong in my thinking? Is there something I don't know? I am really upset about this from start to finish. If there was something to teach me, this would have been the perfect opportunity for him to do so, but he instead chose to make a mockery not only of me and my practice but another doctor as well, and in front of other people. But again, the big issue is the patients care. What can you guys tell me?